We need to understand and address the causes of resident burnout, not just the symptoms. Interventions to reduce resident burnout will increase the meaning we find in our profession, and include teaching effective teamwork, and learning the patient as a person.
Lifelong Learning in Clinical Excellence | October 2, 2018 | 3 min read
By Sanjay Desai, MD, Johns Hopkins University School of Medicine
Burnout is a threat to US healthcare. It affects all stakeholders in our system, either as a physician, a co-worker, or a patient.
What drives burnout and how can we reduce it?
Many of us are trying to understand the drivers of burnout so that interventions can be made. This is important because to durably impact burnout, its causes must be treated. Some argued a root cause was longer duty hours. Based on rigorous study, we now know that burnout is very high for interns and residents, but not different based on shorter or longer duty hour policies (1). This leaves us with a need to understand what does drive burnout and what can we do to reduce it.
Popular interventions only target the symptoms of burnout
Because of the severity of this issue, many have already begun interventions to improve burnout. The most common are wellness programs for residents which often include personal health management time, healthy snacks, and massage sessions. While well intended, these programs primarily target symptoms rather than prevention of burnout. These initiatives are created in part because their products seem relevant, are highly visible and accessible, and quick to implement. However, if we continue these investments without deliberate study and other efforts, we could perpetuate an inherently broken cycle. To reduce physician burnout, we must better understand its causes. There are potential causes at the program level and at levels beyond the program. Search for variables that will enhance our sense of purpose are particularly compelling for me.
The need to teach effective teamwork
Program-level variables that may influence burnout development include rotation length and sequences, work compression, time at bedside, time for reflection, and fatigue management skills. We have shown burnout is driven significantly by the ‘team-learning behavior’ on the clinical teams (2). Therefore, learning and practicing effective teamwork can help us provide the best care and reduce burnout.
Returning to learning the patient as a person
In addition, our patients are too often marginalized because of the way we practice or teach clinical care. Leaders from our own institution have described how we must return to learning the patient as a person (3). This seemingly simple concept can increase the purpose physicians feel in their days and may reduce burnout. Understanding and testing interventions on these micro variables should be a focus of graduate medical education committees and training program leaders.
There are drivers beyond the local learning environment that influence the development of burnout as well. These factors may include the obligatory demands of the electronic medical record, societal and economic disparities that affect our patients access to healthcare resources, healthcare delivery barriers outside of the clinics and hospitals, increasing volumes of patients requiring inpatient care with an increasing burden of illness and complexity of disease, and inadequate mental and social health services for our patients between episodes of care.
These factors have a pervasive impact on the course of our patients’ conditions. By not teaching about the influence of these forces, our trainees are often left with unrealistic expectations and a false sense of control (4). The disparity between their perceived influence over a patient’s health and their actual influence, because the patient couldn’t get a medicine, or see a specialist, or stay in rehab, or change a triggering home environment, can leave our trainees with a feeling of helplessness.
We can improve our practice by talking about these larger issues, engaging with advocacy and professional societies, and becoming more involved with the communities in which we practice. These approaches may promote the meaning of our roles and, thereby, reduce burnout. Understanding and testing interventions on these macro variables should be a focus of policy makers, the regulatory agencies, and leaders of academic medical centers.
In the end, solving the issue of physician burnout is urgent because it affects our health and the health of our patients. The most important next steps are to systematically identify the drivers, design feasible interventions, and measure their effectiveness. I believe our community will improve this situation, not because we are smarter or more resourceful, but simply because there are too many of us that care.